Expense: Still the American Healthcare Dilemma?

Two-thirds of Americans are happy with “the way the health care system is working for them,” a June Gallup poll found. That measure has remained generally consistent since the research firm first began tracking healthcare satisfaction in the middle of March in order to gauge how the changes brought on by the Affordable Care Act were impacting Americans.

“Americans’ high level of satisfaction with how the healthcare system is treating them suggests that healthcare is not in a crisis for most Americans,” the report said. “At the same time, that 30% of the adult population — more than 70 million people — is not satisfied with the healthcare system underscores the need for improvement.”

While it helped that Affordable Care Act enrollments topped the Obama administration’s highest estimate of 7 million, that figure is not the most important measure of the reform’s success. If those exchange policies are deemed to be affordable and the coverage judged to be good, then the future success of the Affordable Care Act will be more assured.

For the Obamacare narrative to be one of growing success, the experiences of those Americans who benefit from the changes to the insurance system — including low- and middle-income earners qualifying for subsidies and those with preexisting conditions who cannot be turned away by insurers — will have to outweigh the burden the reform may place on those who find their premiums too expensive, want to visit doctors out of their network, and consider their deductibles too high.

When examining how the Affordable Care Act has changed the American public’s perception of its healthcare system, health insurance status is the most significant predictor of satisfaction. The highest rate of satisfaction, 77 percent, is found among Americans with military or veteran health coverage. Medicare or Medicaid beneficiaries follow, with 76 percent, while 70 percent of Americans with union or employer-sponsored plans and 66 percent of self-insured Americans expressed satisfaction.

By comparison, those Americans without insurance were more dissatisfied with the healthcare system. Only 36 percent of those respondents said they were content, and 60 percent said they were unhappy.

According to Gallup, approximately 13 percent of the U.S. adult population remains uninsured, even after the implementation of Obamacare’s individual insurance mandate in January. Survey data have confirmed that the country’s uninsured rate is declining as a result of the healthcare reform. Data show that across the entire United States, the share of Americans without health insurance has steadily declined since reaching a peak at 18 percent in the third quarter of 2013; it now stands at 13.4 percent.

Americans who remain uninsured are half as likely as those with insurance to express satisfaction with how the U.S. healthcare system works for them. One in three uninsured Americans are satisfied, and nearly an equal share of insured Americans are dissatisfied.

There is evidence that the law remains deeply unpopular. Several thousand interviews conducted by Gallup between May 21 and 25 revealed that “as of yet, there is no sign that Americans think the new healthcare law is having a net positive effect on their healthcare situations.” A majority of Americans reported that the Affordable Care Act has done little to change their “personal situations” since the research firm first started asking the question in 2012. But since the reform’s cornerstone provision, the online insurance marketplaces, launched in October, public sentiment has gradually grown more positive.

Expense has been highlighted over and over again as the primary cause of healthcare dysfunction in the United States. While the Affordable Care Act sought to reduce healthcare costs through a number of measures and make healthcare more accessible, those changes have yet to quantified.

Data from the Commonwealth Fund, a nonprofit institution specializing in healthcare issues, shows that the U.S. healthcare system is the most expensive in the world when it comes to healthcare outcomes. Comparing the healthcare systems of Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom, the United States placed last (or almost last) in measures of health access, efficiency, and equity. Studies conducted by the Institute of Medicine, McKinsey, and the Rand Corp. have produced similar results.

The abstract of the report was quick to clarify that the data for the study were collected before the U.S. “made significant strides adopting health information technology and undertaking payment and delivery system reforms spurred by the Affordable Care Act.”

As implementation of the law continues, it “could further encourage more affordable access and more efficient organization and delivery of health care, and allow investment in preventive and population health measures that could improve the performance of the U.S. health care system.” Commonwealth Fund researchers suggest that the U.S. could rise in future rankings.

To the authors of the report, the underperformance of the United States is of little surprise, given that the U.S. is the only industrialized country without universal health insurance coverage, along with its high numbers of uninsured individuals. The United Kingdom, which has a single-payer healthcare system, ranked first, followed by Switzerland, which has a compulsory healthcare system like the U.S., although insurers are not allowed to profit from their basic insurance plans.

Both the United States and the United Kingdom placed at the bottom of the health living scale, with the U.S. ranking last overall thanks to poor scores on all three indicators: infant mortality, healthy life expectancy at age 60, and mortality from preventable conditions, such as high blood pressure.

And while the United States placed last in health care outcomes, it spends the greatest percentage of gross domestic product on healthcare. At 17.7 percent of GDP, U.S. healthcare spending is greater than all other countries included in the survey; Australia only spends 8.9 percent. Many attribute the higher spending in the American health care system to big business. The argument goes that pharmaceutical companies, insurers, for-profit hospitals, and even some doctors divert health care resources to shareholders, raising per capita healthcare costs and impacting healthcare outcomes.

Most concerning perhaps is the fact that the United States has the least equity of care between high-income and low-income patients. “The U.S. health care system is not the ‘fairest of them all,’” the authors of the study wrote. “At least from the viewpoint of those who use it to stay healthy, get better, or manage their chronic illnesses, or who are vulnerable because of low income and poor health.” The disparity in care between high-income and low-income patients has dragged the United States down in the rankings from poor to bad.

Income disparity alone is not exacerbating America’s healthcare problems. Conventional wisdom holds that low-income earners in America are also more likely to be obese, and therefore more unhealthy. However, the relationship between economic status and obesity is far more complicated than that, and obesity affects Americans in all income brackets. The obesity problem in the United States is well documented; the most recent research shows 35 percent of the adult American population to be obese, while only 11 percent of the world’s adult population is obese.